Cerebral Blood Flow Velocity and Cognitive Function Preceding Post‐Exercise Syncope

the cerebral blood flow velocity (CBFV): Influence of halothane and cerebral CO 2 reactivity. Objective: This controlled study was designed to investigate 1.) the effects of 0,8% halothane and 2.) the effects of a variation in PaCO 2 on the relationship between global cerebral blood flow (CBF) and middle cerebral artery flow velocity (CBFV MCA ). Method: With ethical committee approval and informed patient consent we investigated 10 patients undergoing coronary artery bypass surgery. Measurements were performed under fentanyl/midazolam anaesthesia prior to the start of surgery. First, during a baseline period, ventilation was changed in a random sequence to achieve two different levels of arterial PCO 2 (30 and 50 mmHg, respectively). Consequently, measurements were repeated during application of 0.8% halothane at identical PaCO 2 levels. Measurements of global CBF were performed by the Kety-Schmidt-technique with argon as an indicator. Simultaneously, CBFV MCA was recorded by use of a 2-MHz transcranial Doppler system. Results: Application of 0.8 % halothane caused a significant decrease in cerebrovascular resistance (CVR) both at hypocapnia and hypercapnia by 36 and 23 %, respectively. Because of a concomitant reduction in cerebral perfusion pressure (CPP), however, CBF remained unchanged during application of halothane. The relationship between CBF and CBFV MCA was not altered when compared to the baseline period. Similarly, CO 2 reactivity of CBF and CBFV MCA remained unchanged. CO 2 reactivity of CBF significantly exceeded CO 2 reactivity of CBFV MCA . Conclusion: The results of this clinical study demonstrate that Doppler-sonographic estimation of relative changes in CBF is not altered by application of 1 MAC halothane indicating that the decrease in CVR is not associated with a vasodilation of the proximal segments of basal cerebral arteries. The difference between CO 2 reactivity of CBF and CBFV MCA , however, suggests that CO 2 -induced changes in CBF are slightly underestimated by TCD monitoring of CBFV MCA .

The aim of this study was to determine whether inhibition of nitric oxide synthase (NOS) alters dynamic cerebral autoregulation in humans. Beat-to-beat blood pressure (BP) and cerebral blood flow (CBF) velocity (transcranial Doppler) were measured in eight healthy subjects in the supine position and during 60 degrees head-up tilt (HUT). NOS was inhibited by intravenous NG-monomethyl-L-arginine (L-NMMA) infusion. Dynamic cerebral autoregulation was quantified by transfer function analysis of beat-to-beat changes in BP and CBF velocity. Pressor effects of L-NMMA on cerebral hemodynamics were compared with those of phenylephrine infusion. In the supine position, L-NMMA increased mean BP from 83+/-3 to 94+/-3 mmHg (P < 0.01). However, CBF velocity remained unchanged. Consequently, cerebrovascular resistance index (CVRI) increased by 15% (P < 0.05). BP and CBF velocity variability and transfer function gain at the low frequencies of 0.07-0.20 Hz did not change with L-NMMA infusion. Similar changes in mean BP, CBF velocity, and CVRI were observed after phenylephrine infusion, suggesting that increase in CVRI after L-NMMA was mediated myogenically by increase in arterial pressure rather than a direct effect of cerebrovascular NOS inhibition. During baseline tilt without L-NMMA, steady-state BP increased and CBF velocity decreased. BP and CBF velocity variability at low frequencies increased in parallel by 277% and 217%, respectively (P < 0.05). However, transfer function gain remained unchanged. During tilt with L-NMMA, changes in steady-state hemodynamics and BP and CBF velocity variability as well as transfer gain and phase were similar to those without L-NMMA. These data suggest that inhibition of tonic production of NO does not appear to alter dynamic cerebral autoregulation in humans.

To examine the influence of sleep state, respiratory pattern, and ventilation on cyclical fluctuations (CF) in cerebral blood flow (CBF) velocity (CBFV), we studied 21 'healthy' preterm infants: birth weight 1,790 +/- 162 g (SEM), study weight 1,960 +/- 165 g, gestational age 32 +/- 1 weeks, postnatal age 20 +/- 4 (range 8-57) days. The CBFV was measured using on-line pulsed Doppler ultrasound by insonating the middle cerebral artery. Breathing was measured using a flow through system. The sleep state was monitored according to conventional criteria. Three hundred and seventy-five epochs of 1 min each were analyzed; 207 during quiet sleep (QS) and 168 during rapid eye movement (REM) sleep. CFs in CBFV were detected in all babies. The frequency of CF ranged from 0.5 to 6 cycles/min. The proportion of epochs showing CF was similar during both sleep states (56% QS vs. 59% REM; p = NS). Although the mean CBFV (cm/s) was similar in these two sleep states, the mean coefficient of variation, a measure of CF amplitude, was significantly higher during REM as compared with QS (6 +/- 0.5 vs. 4.3 +/- 0.2%; p < 0.05). Similarly, the mean CBFVs were similar with various respiratory patterns, but the coefficient of variation was significantly higher in periodic and apneic patterns as compared with regular and irregular respiratory patterns (5.6 +/- 0.6% periodic, 5.6 +/- 0.3% apneic, 3.6 +/- 0.3% regular, and 4.1 +/- 0.5% irregular, p < 0.05). The amplitude of CF was associated with the variability of the heart rate (p < 0.05), but not with the variability of the respiratory measurements. These findings suggest: (1) REM sleep is associated with a greater CBF variability than QS, and (2) periodic and apneic breathing are associated with a greater CBF variability than regular or irregular breathing. We speculate that sleep state and respiratory pattern do not determine but modulate the CBF. Our data suggest that in studies involving interpretation of CBFV data using the Doppler technique, breathing patterns should be taken into account in addition to sleep state.

BackgroundGeneral anaesthesia is associated with neurocognitive deficits in infants after noncardiac surgery. Disturbances in cerebral perfusion as a result of systemic hypotension and impaired autoregulation may be a potential cause. Our aim was to study cerebral blood flow (CBF) velocity continuously during general anaesthesia in infants undergoing noncardiac surgery and compare variations in CBF velocity with simultaneously measured near-infrared spectroscopy (NIRS), blood pressure, and heart rate. MethodsNeoDoppler, a recently developed ultrasound system, was used to monitor CBF velocity via the anterior fontanelle during induction and maintenance of general anaesthesia until the start of surgery, and during recovery. NIRS, blood pressure, and heart rate were monitored simultaneously and synchronised with the NeoDoppler measurements. ResultsThirty infants, with a median postmenstrual age at surgery of 37.6 weeks (range 28.6–60.0) were included. Compared with baseline, the trend curves showed a decrease in CBF velocity during induction and maintenance of anaesthesia and returned to baseline values during recovery. End-diastolic velocity decreased in all infants during anaesthesia, on average by 59%, whereas peak systolic- and time-averaged velocities decreased by 26% and 45%, respectively. In comparison, the reduction in mean arterial pressure was only 20%. NIRS values were high and remained stable. When adjusting for mean arterial pressure, the significant decrease in end-diastolic velocity persisted, whereas there was only a small reduction in peak systolic velocity. ConclusionsContinuous monitoring of CBF velocity using NeoDoppler during anaesthesia is feasible and may provide valuable information about cerebral perfusion contributing to a more targeted haemodynamic management in anaesthetised infants.

Cerebral perfusion and oxygenation after the Norwood procedure: Comparison of right ventricle–pulmonary artery conduit with modified Blalock–Taussig shunt

BACKGROUND: Short-term fluid loading is used as part of post-spaceflight medical procedures and clinical treatment in hospitals. Hypervolemia with hemodilution induced by rapid fluid infusion reportedly impaired dynamic cerebral autoregulation. However, the effects on intracranial pressure (ICP) remain unknown. Therefore, we estimated ICP noninvasively (nICP) to examine whether rapid fluid infusion would raise ICP.METHODS: Twelve healthy male volunteers underwent two discrete normal saline (NS) infusions (15 and 30 ml · kg-1 stages, NS-15 and NS-30, respectively) at a rate of 100 ml · min-1. The cerebral blood flow (CBF) velocity (CBFv) waveform from the middle cerebral artery obtained by transcranial Doppler ultrasonography was recorded, as was the arterial blood pressure (ABP) waveform at the radial artery obtained by tonometry. We then used these waveforms to calculate nICP, cerebral artery compliance, and the pulsatility index (PI) in an intracranial hydraulic model.RESULTS: nICP increased significantly in both infusion stages from preinfusion (preinfusion: 7.6 ± 3.4 mmHg; NS-15: 10.9 ± 3.3 mmHg; NS-30: 11.7 ± 4.2 mmHg). No significant changes were observed in cerebral artery compliance or PI. Although ABP did not change in any stage, CBFv increased significantly (preinfusion: 67 ± 10 cm · s-1; NS-15: 72 ± 12 cm · s-1; NS-30: 73 ± 12 cm · s-1).DISCUSSION: Hypervolemia with hemodilution induced by rapid fluid infusion caused increases in nICP and CBFv. No changes were observed in cerebral artery compliance or PI related to cerebrovascular impedance. These findings suggest that rapid fluid infusion may raise ICP with increased CBF.Kurazumi T, Ogawa Y, Takko C, Kato T, Konishi T, Iwasaki K. Short-term volume loading effects on estimated intracranial pressure in human volunteers. Aerosp Med Hum Perform. 2022; 93(4):347-353.

The aim of this study was to differentiate the mechanical effects of the Valsalva maneuver (VM) from the effects of changes in autonomic neural activity on cerebral hemodynamics in humans. Nine healthy subjects performed the VM before and after autonomic ganglionic blockade with trimethaphan. Blood pressure (BP) was measured in the radial artery with an indwelling catheter or at the finger by Finapres. Cerebral blood flow (CBF) velocity was measured in the middle cerebral artery with transcranial Doppler; end-tidal CO2 was measured by mass spectrometry. Before blockade, during phase II of the VM, BP was reduced by 27% and CBF velocity was reduced by 33% (magnitude of changes during phase II divided by baseline measurements before the VM, P<0.05). Cerebrovascular conductance index (CVCI) increased by 21%. During phase IV, overshoot of CBF velocity was proportionately greater than that of BP (46% versus 30%). After blockade, during phase II, BP fell to a much greater degree by 50%, while CBF velocity decreased even more by 60% associated with an increase in CVCI by 33%. During phase IV, despite the absence of BP overshoot, CBF velocity still increased by 55% and CVCI by 33%. Both were significantly greater than before blockade. After ganglionic blockade, cerebral autoregulation is unable to prevent the substantial fall in CBF induced by the marked reduction in BP during the VM. Enhanced phase IV increases in both CBF velocity and CVCI reflect the intrinsic characteristics of cerebral hyperemic responses, which are likely modified in part by the removal of vasoconstrictor effects of autonomic neural activity elicited during the VM.

Effect of diclofenac on cerebral blood flow velocity in patients with supratentorial tumours

Acute fasting has been adopted in fitness communities, and has been practiced for religious purposes. Short‐term fasting does not affect cognitive function, and therefore may not affect cerebrovascular responsiveness. Cerebral blood flow velocity increases with mental stress, however the combined influences of an acute fast and mental stress on cerebrovascular responses are unknown. The purpose of this study was to describe the effects of a 24‐hour, water‐only fast on cerebral blood flow velocity responses to mental stress in a small cohort of research volunteers. Eight young healthy participants (7 males, average age of 25 yrs) completed the protocol in a fed state (4 hours post‐prandial) and in a fasted state (24–25 hours post‐prandial). Whole blood was collected and analyzed before experimentation for β‐Ketones, total cholesterol, HDL, LDL, triglycerides (TRG), and glucose. With participants in a supine position, we recorded the electrocardiogram, beat‐to‐beat arterial pressure (finger plethysmography), and cerebral artery blood flow velocity (transcranial Doppler). After a 5‐min baseline, participants performed 5‐min of mental stress via mental arithmetic (rapid continuous subtraction). Mental stress reactivity was calculated as the mean stress response for each minute of mental stress minus the corresponding 5‐min baseline. The minute‐by‐minute reactivity was analyzed with repeated measures ANOVA. Blood variables were analyzed with paired t‐tests. Data were expressed as mean ± SE. Baseline blood variables were different in the fasted compared with the fed state: TRG (112±14 fed vs. 68±13 mg/dL fasted; p&lt;.01) Glucose (101±5 fed vs. 79±6 mg/dL fasted; p&lt;.01) and β‐Ketone (.1±.01 fed vs. .5±.2 mmol/L fasted; p&lt;.05). Mean arterial pressures and heart rate reactivities to mental stress were not affected by fasting. Mean cerebral blood flow velocity reactivity to mental stress was reduced in the fasted compared with the fed condition (condition × time, p&lt;.01), with a particular divergent responsiveness during the third minute of mental stress. The results we present are new, but preliminary. We did not attempt to ascribe mechanisms to fasting and cerebral blood flow velocity reactivity during mental stress. The changes we observed with our preliminary data set suggest that fasting, and associated changes of plasma glucose, β‐Ketone and TRG may be associated with reductions of cerebral blood flow velocity during mental stress.Support or Funding InformationSupport was provided by the Michigan Space Grant Consortium and The Portage Health Foundation of Michigan.

To assess the effects of the tilt test on cerebral blood flow velocity (CBFV), blood pressure, and heart rate in patients with Parkinson's disease (PD) without symptomatic orthostatic dysautonomia. Thirty patients with idiopathic PD and 15 healthy controls were included. Mean middle cerebral artery blood flow velocity (CBFV) was recorded with transcranial Doppler sonography, while systolic (SBP), diastolic (DBP), and mean (MBP) blood pressure and heart rate were measured in the supine position and after passive tilting. There was no difference in resting SBP, DBP, or MBP between patients and controls. CBFV was lower at rest in patients than in controls and dropped significantly and similarly after tilting in both groups. SBP decreased in patients during the first 5 minutes of tilting (p < 0.05), whereas it increased progressively after the first minute in controls. In patients, DBP decreased slightly and MBP dropped during the first 2 minutes, then increased. Baseline heart rate was higher in patients than in controls (p < 0.05) and increased in both groups during tilting. Our results suggest that cardiovascular responses to tilting are delayed in PD patients and that subclinical autonomic dysfunction may be present even in the absence of symptomatic orthostatic dysautonomia.

Cerebral blood flow (CBF) increases from rest to ∼60% of peak oxygen uptake (VO(2peak)) and thereafter decreases towards baseline due to hyperventilation-induced hypocapnia and subsequent cerebral vasoconstriction. It is unknown what happens to CBF in older adults (OA), who experience a decline in CBF at rest coupled with a blunted ventilatory response during VO(2peak). In 14 OA (71 ± 10 year) and 21 young controls (YA; 23 ± 4 years), we hypothesized that OA would experience less hyperventilation-induced cerebral vasoconstriction and therefore an attenuated reduction in CBF at VO(2peak). Incremental exercise was performed on a cycle ergometer, whilst bilateral middle cerebral artery blood flow velocity (MCA V (mean); transcranial Doppler ultrasound), heart rate (HR; ECG) and end-tidal PCO(2) (P(ET)CO(2)) were monitored continuously. Blood pressure (BP) was monitored intermittently. From rest to 50% of VO(2peak), despite greater elevations in BP in OA, the change in MCA V(mean) was greater in YA compared to OA (28% vs. 15%, respectively; P < 0.0005). In the YA, at intensities >70% of VO(2peak), the hyperventilation-induced declines in both P(ET)CO(2) (14 mmHg (YA) vs. 4 mmHg (OA); P < 0.05) and MCA V(mean) (-21% (YA) vs. -7% (OA); P < 0.0005) were greater in YA compared to OA. Our findings show (1), from rest-to-mild intensity exercise (50% VO(2peak)), elevations in CBF are reduced in OA and (2) age-related declines in hyperventilation during maximal exercise result in less hypocapnic-induced cerebral vasoconstriction.

Blood pressure control with glyceryl trinitrate during electroconvulsive therapy in a patient with cerebral aneurysm

Introduction: Vaso-occlusion in Sickle Cell Anaemia (SCA) results in the narrowing of the major cerebral blood vessel, predisposing affected children to cerebrovascular accidents (CVA). The risk of CVA can be assessed with cerebral blood flow velocities measurement using a transcranial Doppler ultrasound. Objective: To determine the cerebral blood flow velocities in children with SCA aged 2-16 years. Methods: This was a hospital-based, cross-sectional study of children with SCA conducted between April and September 2023. Transcranial Doppler ultrasound was used to assess the anterior and middle cerebral arteries. Results: A total of 102 children out of the 150 enrolled were screened within the study period. The values obtained from this procedure were categorised as abnormal (≥200cm/s), conditional (170 – 199cm/s) and normal or standard risk (&lt; 170cm/s). Children with abnormal blood velocities are at high risk of CVA, while children whose velocities fall within the conditional range are at moderate risk for CVAs. The prevalence of abnormal cerebral blood flow velocity above 170cm/second was 17.6% (13.7% was in the conditional risk zone and 3.9% in the high-risk zone). All the subjects in the high-risk zone were aged 2-6 years, and 75% were females. Conclusion: The prevalence of abnormal cerebral blood flow velocity in the cohort of SCA children is 17.6%, with 10-40% annual risk for stroke. Identification of children at risk for a CVA helps in the primary prevention of CVA by prompt therapy institutions.

Background: In premature infants, intraventricular hemorrhage occurs more commonly in the left than the right hemisphere. We have demonstrated previously that cerebral blood flow velocity is lower in the left than the right middle cerebral artery in the first few hours after birth. This may be due to the open ductus arteriosus. Objective: To test the hypothesis that blood flow velocity is lower in the left than the right middle cerebral artery only when the ductus arteriosus is open. Study Design: Infants born at 25–33 weeks’ gestation were enrolled. Middle cerebral artery blood flow velocities and coefficients of variation were measured on the left, followed by the right, on days 1 and 7 of life. Echocardiography identified 67 infants (25–33 weeks, 517–2,371 g) whose ductus arteriosus was open on day 1 and closed on day 7. Results: Systolic (26.4 ± 7.4 vs. 29.6 ± 7.2 cm/s), mean (12.4 ± 4.0 vs. 15.6 ± 4.6 cm/s) and end-diastolic (5.3 ± 2.2 vs. 6.8 ± 2.9 cm/s) blood flow velocities were lower (p < 0.01) and the corresponding coefficients of variation were higher (p < 0.01) on the left on day 1. Neither the absolute Doppler blood flow velocities nor the coefficients of variation differed between the left and right sides on day 7. Conclusions: Blood flow velocity is lower and more variable in the left compared to the right middle cerebral artery on day 1 of life in premature infants. These differences are not found on day 7. We speculate that this difference is due to the associated ductus arteriosus patency.

Sleep Apnea Syndrome and Cerebral Hemodynamics